It is always a good idea to develop your own systematic way of performing a quick and structured evaluation (and documentation) of every paediatric patient under your care.
Here is one such approach, a rough guide to performing a paediatric primary survey taken from notes I made during an advanced paediatric life support course ( and if you are in Australasia and looking for an excellent one….here is my recommendation: APLS ).
Airway & Breathing: Look, Listen, Feel.
Tachypnoea at rest indicates need for increased ventilation.
- Lung or airway disease OR
- Metabolic acidosis
Bradypnoea at rest:
- Cerebral depression
- Pre-terminal state
Intercostal, sub-costal, sternal = increased effort of breathing. More easily seen in infants as they have a more compliant chest wall.
Remember: Recession decreases as exhaustion increases.
Stridor = laryngeal or tracheal obstruction (insp usually > exp)
Wheezing = lower airway narrowing (usually greater during expiration)
Grunting = exhalation against partially closed glottis (sign of severe respiratory distress!) Characteristically seen in pneumonia & pulmonary oedema.
May also be seen in raised ICP.
Accessory muscle usage: sternomastoid (muscles in anterior part of neck). In infants this results in an appearance of head bobbing.
Flaring of the Alae Nasi.
Gasping = severe hypoxia. Pre-terminal sign.
3 EXCEPTIONS where you may not see increased effort of breathing in unwell child:
- Patients with chronic severe respiratory problems.
- Cerebral depression from raised ICP, OR poisoning, OR encephalopathy.
- Patients with neuromuscular disease (eg Spinal muscular atrophy, muscular dystrophy).
Chest expansion in child.
Abdominal excursion in infant.
Auscultation: Listen for
- Reduced air entry.
- Asymmetrical air entry.
- Bronchial breath sounds.
Note to self: Don’t get all arty when quickly auscultating the chest. Place stethoscope over anterior chest wall (mid-clavicular line) and compare with other side. Then auscultate under both axilla. Done.
SaO2: Less accurate when < 70%, OR shock, OR carboxyhaemaglobin.
EFFECT: (on other organs)
Heart rate: Hypoxia produces tachycardia in older infant in child (as does anxiety).
Severe or prolonged hypoxia may lead to bradycardia.
- catecholamine release = vasoconstriction.
- Cyanosis is a LATE sign.
- Central cyanosis = impending respiratory arrest!
- Note: anaemia may mask cyanosis.
- Patients with congenital heart disease may remain cyanotic despite O2.
Mental Status: Note if agitated or drowsy.
Heart rate: increased in shock due to catecholamine release + decreased stroke volume (SV).
(Infants have small, fixed SV therefore to increase cardiac output they need to increase heart rate).
Pulse Volume: Good indication of perfusion: compare central and peripheral pulses.
Weak central + absent peripheral = advanced shock.
Bounding pulses = high cardiac output (eg septic shock)
Cap Refill: Press on sternum for 5 sec.
Normal = 2–3 sec cap refill.
Note: Poor skin perfusion or low ambient temp reduces reliability.
Normal: 80+(age x 2).
Note: changes in BP are a late sign.
Correct cuff size is important: >80% of length of upper arm.
Effects (on other organs):
Respiratory: Increased resp rate with increased tidal volume but no recession = metabolic acidosis.
Skin: Look for mottled / Cool.
Urine output: At least
1m/kg/hr for children.
2ml/kg/hr for infants.
Level of consciousness:
Initially, use AVPU (Alert | Voice | Pain | Unresponsive).
P or U = GCS of 8 or less.
Posture: seriously ill are usually hypotonic.
Pupils: check for size, reactivity and equality.
Finally: Don’t ever forget glucose! (Consider need for cap BSL).